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Background and Objective: The purpose of this study was to describe statewide perinatal quality improvement (QI) activities, specifically implementation of Alliance for Innovation on Maternal Health (AIM) patient safety bundles and use of teamwork and communication tools in obstetric units in Oklahoma and Texas., Methods: In January-February 2020, we conducted a survey of AIM-enrolled hospitals in Oklahoma (n = 35) and Texas (n = 120) to gather data on obstetric unit organization and QI processes. Data were linked to hospital characteristics information from the 2019 American Hospital Association survey and hospitals' maternity levels of care from state agencies. We generated descriptive statistics for each state and created an index to summarize adoption of QI processes. We fitted linear regression models to examine how this index varied by hospital characteristics and self-reported ratings for patient safety and AIM bundle implementation., Results: Most obstetric units had standardized clinical processes for obstetric hemorrhage (94% Oklahoma; 97% Texas), massive transfusion (94% Oklahoma; 97% Texas), and severe hypertension in pregnancy (97% Oklahoma; 80% Texas); regularly conducted simulation drills for obstetric emergencies (89% Oklahoma; 92% Texas); had multidisciplinary QI committees (61% Oklahoma; 83% Texas); and conducted debriefs after major obstetric complications (45% Oklahoma; 86% Texas). Few obstetric units offered recent staff training on teamwork and communication to their staff (6% Oklahoma; 22% Texas); those who did were more likely to employ specific strategies to facilitate communication, escalate concerns, and manage staff conflicts. Overall, adoption of QI processes was significantly higher in hospitals in urban than rural areas, teaching than nonteaching, offering higher levels of maternity care, with more staff per shift, and greater delivery volume (all P < .05). The QI adoption index scores were strongly associated with respondents' ratings for patient safety and implementation of maternal safety bundles (both P < .001)., Conclusions: Adoption of QI processes varies across obstetric units in Oklahoma and Texas, with implications for implementing future perinatal QI initiatives. Notably, findings highlight the need to reinforce support for rural obstetric units, which often face greater barriers to implementing patient safety and QI processes than urban units., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To understand healthcare worker (HCW) perceptions of infection risk associated with aerosol-generating procedures (AGPs) and their affective response to performing AGPs., Design: Systematic review., Methods: Systematic searches of PubMed, CINHAL Plus, and Scopus were conducted using combinations of selected keywords and synonyms. To reduce bias, titles and abstracts were screened for eligibility by 2 independent reviewers. Also, 2 independent reviewers extracted data from each eligible record. Discrepancies were discussed until consensus was reached., Results: In total, 16 reports from across the globe were included in this review. Findings suggest that AGPs are generally perceived to place HCWs at high risk of becoming infected with respiratory pathogens and that this perception stimulates a negative affective response and hesitancy to participate in the procedures., Conclusions: AGP risk perception are complex and context dependent but have important influences on HCW infection control practices, decision to participate in AGPs, emotional welfare, and workplace satisfaction. New and unfamiliar hazards paired with uncertainty lead to fear and anxiety about personal and others' safety. These fears may create a psychological burden conducive to burnout. Empirical research is needed to thoroughly understand the interplay between HCW risk perceptions of distinct AGPs, their affective responses to conducting these procedures under various conditions, and their resulting decision to participate in these procedures. Results from such studies are essential for advancing clinical practice; they point to methods for mitigating provider distress and better recommendations for when and how to conduct AGPs., (© The Author(s) 2023.)

Objective: Assess COVID-19 vaccine uptake among veterinarians and describe unvaccinated veterinarians' perceptions of COVID-19 disease and vaccines., Sample: 2,721 (14%) of 19,654 randomly sampled AVMA members., Procedures: A survey of AVMA members was conducted between June 8 and June 18, 2021. Information was collected on COVID-19 experience, vaccination intention, and perceptions of COVID-19 disease and vaccines., Results: A total of 2,721 AVMA members completed the survey. Most respondents reported receiving a COVID-19 vaccine (89% [2,428/2,721]). Most unvaccinated respondents disagreed with concerns about contracting (67% [196/292]) or being harmed by (65% [187/287]) COVID-19 but agreed with concerns about short- (79% [228/290]) and long-term (89% [258/289]) side effects of COVID-19 vaccines. Over 91% (268/292) did not agree that COVID-19 vaccine benefits outweigh the risk. Although 83% (244/293) of unvaccinated respondents reported being unlikely to get a COVID-19 vaccine, 47% (137/291) agreed they would be more likely if they knew people vaccinated without serious side effects. Perceptions of COVID-19 disease severity and susceptibility, beliefs about COVID-19 vaccine benefits, and barriers and facilitators to COVID-19 vaccination varied with vaccination intention., Clinical Relevance: Results of the AVMA survey suggested that COVID-19 vaccination was widespread among veterinarians in June 2021. Understanding unvaccinated respondents' health beliefs about COVID-19 and COVID-19 vaccines may facilitate veterinarian vaccination participation. Veterinarians who abstained from COVID-19 vaccination cited concerns about the safety, efficacy, and necessity of COVID-19 vaccines. Our results suggested that demonstrating vaccine safety and a favorable risk-to-benefit ratio of vaccination may help reduce vaccine hesitancy and increase uptake of COVID-19 vaccines among veterinarians.

Background: Social ties between health care workers may be an important driver of job satisfaction; however, research on this topic is limited., Purpose: We used social network methods to collect data describing two types of social ties, (a) instrumental ties (i.e., exchange of advice that enables work) and (b) expressive ties (i.e., exchange of social support), and related those ties to workers' job satisfaction., Methodology: We surveyed 456 clinicians and staff at 23 primary care practices about their social networks and workplace attitudes. We used multivariable linear regression to estimate the relationship between an individual's job satisfaction and two network properties: (a) eigenvector centrality (a measure of the importance of an individual in a network) and (b) ego network density (a measure of the cohesiveness of an individual's network). We examined this relationship for both instrumental and expressive ties., Results: Individuals who were more central in the expressive network were less satisfied in their job, b = -0.40 (0.19), p < .05, whereas individuals who had denser instrumental networks were more satisfied in their job, b = 0.49 (0.21), p < .05., Conclusion: Workplace relationships affect worker well-being. Centrality in an expressive network may require greater emotional labor, increasing workers' risk for job dissatisfaction. On the other hand, a dense instrumental network may promote job satisfaction by strengthening workers' access to full information, supporting competence and confidence., Practice Implications: Efforts to increase job satisfaction should consider both the positive and negative effects of social networks on workers' sense of well-being., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: Medical teams play a vital role in the delivery of safe and effective patient care. Toward the goal of becoming a high-reliability health system, the authors posit that the "perfect" medical team is one that develops their attitudes, behaviors, and cognitions (ABCs) to facilitate adaptation., Methods: The authors synthesized the literature (frameworks, measures, and conceptual models) on teamwork in healthcare (k = 161) to develop an evidence-based model of ABCs, which current evidence suggests, are requisite for medical team adaptation. Clinical vignettes were garnered from the media and other sources to illustrate how these ABCs-or failure in using these ABCs-can lead to positive or negative events in healthcare., Results: The resulting model contains the most frequently included ABCs in healthcare teamwork models, measures, and frameworks: psychological safety (41, 25.5%), situation assessment (66, 41.0%), shared mental models (56, 34.8%), team leadership behaviors (78, 48.4%), role awareness (64, 39.7%), team decision-making (61, 37.9%) and planning (41, 25.5%), conflict management (51, 31.7%), task coordination (71, 44.1%), adaptation (46, 28.6%), and backup behavior (54, 33.5%). The authors posit that communication and organizational conditions-other highly cited components-(141, 87.6%, and 90, 55.9%, respectively) serve as moderators of these relationships., Conclusions: The authors argue that each of these ABCs is critical for enhancing team adaptation and subsequently increasing patient safety. A list of practical tools and educational strategies that teams and organizations can use to improve their performance on each of these ABCs is provided., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Formative events during training help shape professional identity and may impact well-being. This study sought to identify formative experiences during anesthesia residency and measure their perceived impact on well-being., Methods: A 24-item survey exploring the frequency and perceived impact of formative events was developed through a rigorous process involving a literature search, consultation with medical education experts, resident focus groups, graduate interviews, and pilot testing. All 80 anesthesiology residents at Johns Hopkins University were invited to participate. We measured the frequency of event exposure and perceived impact on well-being., Results: Seventy-six residents (95%) completed the survey. Event exposure rate ranged from 56.6% to 100%. Events with greatest relative impact (RI) overall included leaving work earlier than expected (RIoverall = 85.8), a patient expresses genuine gratitude (RIoverall = 80.2), identifying a faculty role model (RIoverall = 75.7), and having a patient die under my care (RIoverall = 75.6). There was no statistically significant difference on RI for positive versus negative events. The perceived impact of events on well-being varied by gender., Conclusions: This work provides clarity for residency program leaders and educators about the commonly experienced formative events that have the greatest perceived impact on resident well-being. These results may inform curricular planning and can suggest times when trainees may need attention or support. Future research should evaluate the direct impact of formative events on well-being and the success of related interventions., Competing Interests: Conflicts of interest: None, (© 2019 Society for Education in Anesthesia.)

Teams have been a ubiquitous structure for conducting work and business for most of human history. However, today's organizations are markedly different than those of previous generations. The explosion of innovative ideas and novel technologies mandate changes in job descriptions, roles, responsibilities, and how employees interact and collaborate. These advances have heralded a new era for teams and teamwork in which previous teams research and practice may not be fully appropriate for meeting current requirements and demands. In this article, we describe how teams have been historically defined, unpacking five important characteristics of teams, including membership, interdependence, shared goals, dynamics, and an organizationally bounded context, and relating how these characteristics have been addressed in the past and how they are changing in the present. We then articulate the implications these changes have on how we study teams moving forward by offering specific research questions.

Objective: To systematically assess enhanced personal protective equipment (PPE) doffing safety risks., Design: We employed a 3-part approach to this study: (1) hierarchical task analysis (HTA) of the PPE doffing process; (2) human factors-informed failure modes and effects analysis (FMEA); and (3) focus group sessions with a convenience sample of infection prevention (IP) subject matter experts., Setting: A large academic US hospital with a regional Special Pathogens Treatment Center and enhanced PPE doffing protocol experience.ParticipantsEight IP experts., Methods: The HTA was conducted jointly by 2 human-factors experts based on the Centers for Disease Control and Prevention PPE guidelines. The findings were used as a guide in 7 focus group sessions with IP experts to assess PPE doffing safety risks. For each HTA task step, IP experts identified failure mode(s), assigned priority risk scores, identified contributing factors and potential consequences, and identified potential risk mitigation strategies. Data were recorded in a tabular format during the sessions., Results: Of 103 identified failure modes, the highest priority scores were associated with team members moving between clean and contaminated areas, glove removal, apron removal, and self-inspection while preparing to doff. Contributing factors related to the individual (eg, technical/ teamwork competency), task (eg, undetected PPE contamination), tools/technology (eg, PPE design characteristics), environment (eg, inadequate space), and organizational aspects (eg, training) were identified. Participants identified 86 types of risk mitigation strategies targeting the failure modes., Conclusions: Despite detailed guidelines, our study revealed 103 enhanced PPE doffing failure modes. Analysis of the failure modes suggests potential mitigation strategies to decrease self-contamination risk during enhanced PPE doffing.

Few industries match the scale of health care. In the United States alone, an estimated 85% of the population has at least 1 health care encounter annually and at least one quarter of these people experience 4 to 9 encounters annually. A single visit requires collaboration among a multidisciplinary group of clinicians, administrative staff, patients, and their loved ones. Multiple visits often occur across different clinicians working in different organizations. Ineffective care coordination and the underlying suboptimal teamwork processes are a public health issue. Health care delivery systems exemplify complex organizations operating under high stakes in dynamic policy and regulatory environments. The coordination and delivery of safe, high-quality care demands reliable teamwork and collaboration within, as well as across, organizational, disciplinary, technical, and cultural boundaries. In this review, we synthesize the evidence examining teams and teamwork in health care delivery settings in order to characterize the current state of the science and to highlight gaps in which studies can further illuminate our evidence-based understanding of teamwork and collaboration. Specifically, we highlight evidence concerning (a) the relationship between teamwork and multilevel outcomes, (b) effective teamwork behaviors, (c) competencies (i.e., knowledge, skills, and attitudes) underlying effective teamwork in the health professions, (d) teamwork interventions, (e) team performance measurement strategies, and (f) the critical role context plays in shaping teamwork and collaboration in practice. We also distill potential avenues for future research and highlight opportunities to understand the translation, dissemination, and implementation of evidence-based teamwork principles into practice. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Teams and other collaborative structures have become commonplace in American schools, although historically school staff members functioned more independently from one another. In this article, we describe the growing influence of collaboration and teaming in a variety of school contexts, but focus on the empirical literature on problem-solving teams as reflecting the state of research and practice in the schools. A review of the research on problem-solving teams, using an input-mediator-outcome-input framework, provides evidence for how teaming could become more effective and efficient in this context as well as sets an agenda for what additional research is needed. Key challenges to school teams are considered next, along with recommendations for change. The first challenge is the lack of training of school staff in the key components of teaming. A second issue is the difficulty in implementing teams in the organizational context of schools. (PsycINFO Database Record, ((c) 2018 APA, all rights reserved).)

Objective The aim of this study was to describe the relationship between negative affect (NA), decision-making style, time stress, and decision quality in health care. Background Health care providers must often make swift, high-stakes decisions. Influencing factors of the decision-making process in this context have been understudied. Method Within a sample of labor and delivery nurses, physicians, and allied personnel, we used self-report measures to examine the impact of trait factors, including NA, decision-making style, and perceived time stress, on decision quality in a situational judgment test (Study 1). In Study 2, we observed the influence of state NA, state decision-making style, state time stress, and their relationship with decision quality on real clinical decisions. Results In Study 1, we found that trait NA significantly predicted avoidant decision-making style. Furthermore, those who were higher on trait time stress and trait avoidant decision-making style exhibited poorer decisions. In Study 2, we observed associations between state NA with state avoidant and analytical decision-making styles. We also observed that these decision-making styles, when considered in tandem with time stress, were influential in predicting clinical decision quality. Conclusion NA predicts some decision-making styles, and decision-making style can affect decision quality under time stress. This is particularly true for state factors. Application Individual differences, such as affect and decision-making style, should be considered during selection. Training to reduce time stress perceptions should be provided.

Background: As a result of the recent proliferation of health care team training (HTT), there was a need to update previous systematic reviews examining the underlying structure driving team training initiatives., Methods: This investigation was guided by 10 research questions. A literature search identified 197 empirical samples detailing the evaluation of team training programs within the health care context; 1,764 measures of HTT effectiveness were identified within these samples. Trained coders extracted information related to study design and training development, implementation, and evaluation to calculate percentages detailing the prevalence of certain training features., Results: HTT was rarely informed by a training needs analysis (k = 47, 23.9%) and most commonly addressed communication strategies (k = 167, 84.8%). HTT programs that incorporated practice (k = 163, 82.7%) often employed high-fidelity patient simulators (k = 38, 25.2%) and provided participants with feedback opportunities (k = 107, 65.6%). Participants were typically practicing clinicians (k = 154, 78.2%) with a lower prevalence of health care students (k = 35, 17.8). Evaluations primarily relied on repeated measures designs (k = 123, 62.4%) and self-reported data (k = 1,257, 71.3%). Additional trends were identified and are discussed., Conclusions: Many trends in HTT practice and evaluation were identified. The results of this review suggested that, in the literature, HTT programs are more frequently following recommendations for training design and implementation (for example, providing feedback) in comparison to findings from previous reviews. However, there were still many areas in which improvement could be achieved to improve patient care., (Copyright © 2016 The Joint Commission. Published by Elsevier Inc. All rights reserved.)

As the nature of work becomes more complex, teams have become necessary to ensure effective functioning within organizations. The healthcare industry is no exception. As such, the prevalence of training interventions designed to optimize teamwork in this industry has increased substantially over the last 10 years (Weaver, Dy, & Rosen, 2014). Using Kirkpatrick's (1956, 1996) training evaluation framework, we conducted a meta-analytic examination of healthcare team training to quantify its effectiveness and understand the conditions under which it is most successful. Results demonstrate that healthcare team training improves each of Kirkpatrick's criteria (reactions, learning, transfer, results; d = .37 to .89). Second, findings indicate that healthcare team training is largely robust to trainee composition, training strategy, and characteristics of the work environment, with the only exception being the reduced effectiveness of team training programs that involve feedback. As a tertiary goal, we proposed and found empirical support for a sequential model of healthcare team training where team training affects results via learning, which leads to transfer, which increases results. We find support for this sequential model in the healthcare industry (i.e., the current meta-analysis) and in training across all industries (i.e., using meta-analytic estimates from Arthur, Bennett, Edens, & Bell, 2003), suggesting the sequential benefits of training are not unique to medical teams. Ultimately, this meta-analysis supports the expanded use of team training and points toward recommendations for optimizing its effectiveness within healthcare settings. (PsycINFO Database Record, ((c) 2016 APA, all rights reserved).)

Introduction: Obstetric complications and adverse patient events are often preventable. Teamwork and situational awareness (SA) can improve detection and coordination of critical obstetric (OB) emergencies, subsequently improving decision making and patient outcomes. The purpose of this study was to assess the effectiveness of a team training intervention in improving learning and transfer of teamwork, SA, decision making, and cognitive bias as well as patient outcomes in OB., Method: An adapted TeamSTEPPS training program was delivered to OB clinicians. Training targeted communication, mutual support, situation monitoring, leadership, SA, and cognitive bias. We conducted a repeated measures multilevel evaluation of the training using Kirkpatrick's (1994) framework of training evaluation to determine impact on trainee reactions, learning, transfer, and results. Data were collected using surveys, situational judgment tests (SJTs), observations, and patient chart reviews., Results: Participants perceived the training as useful. Additionally, participants acquired knowledge of communication strategies, though knowledge of other team competencies did not significantly improve nor did self-reported teamwork on the unit. Although SJT decision accuracy did not significantly improve for all scenarios, results of behavioral observation suggest that decision accuracy significantly improved on the job, and there was a marginally significant reduction in babies' hospital length of stay., Discussion: These findings indicate that the training intervention was partially effective, but more work needs to be done to determine the conditions under which training is most effective, and the ways in which to sustain improvements. Future research is needed to confirm its generalizability to additional OB units and departments., ((c) 2015 APA, all rights reserved).)

Background: The aim of this study was to examine the impact of a telemedical robot on trauma intensive care unit (TICU) clinician teamwork (i.e., team attitudes, behaviors, and cognitions) during patient rounds., Materials and Methods: Thirty-two healthcare providers who conduct rounds volunteered to take surveys assessing teamwork attitudes and cognitions at three time periods: (1) the onset of the study, (2) the end of the 30-day control period, and (3) the end of the 30-day experimental period, which immediately followed the control period. Rounds were recorded throughout the 30-day control period and 30-day experimental period to observe provider behaviors. For the initial 30 days, there was no access to telemedicine. For the final 30 days, the rounding healthcare providers had access to the RP-7 robot (Intouch Health Inc., Santa Barbara, CA), a telemedical tool that can facilitate patient rounds conducted away from bedside., Results: Using a one-tailed, one-way repeated-measures analysis of variance (ANOVA) to compare trust at Times 1, 2, and 3, there was no significant effect on trust: F(2, 14)=1.20, p=0.16. When a one-tailed, one-way repeated-measures ANOVA to compare transactive memory systems (TMS) at Times 1, 2, and 3 was conducted, there was no significant effect on TMS: F(2, 15)=1.33, p=0.15. We conducted a one-tailed, one-way repeated-measures ANOVA to compare team psychological safety at Times 1, 2, and 3, and there was no significant effect on team psychological safety: F(2,15)=1.53, p=0.12. There was a significant difference in communication between rounds with and without telemedicine [t(25)=-1.76, p<0.05], such that there was more task-based communication during telerounds. Telemedicine increased task-based communication and did not negatively impact team trust, psychological safety, or TMS during rounds., Conclusions: Telemedicine may offer advantages for some teamwork competencies without sacrificing the efficacy of others and may be adopted by intact rounding teams without hindering teamwork.

Background: Teamwork is a vital component of optimal patient care. In both clinical settings and medical education, a variety of approaches are used for the development of teamwork skills. Yet, for team members to receive the full educational benefit of these experiential learning opportunities, postsimulation feedback regarding the team's performance must be incorporated. Debriefings are among the most widely used form of feedback regarding team performance. A team debriefing is a facilitated or guided dialogue that takes place between team members following an action period to review and reflect on team performance. Team members discuss their perceptions of what occurred, why it occurred, and how they can enhance their performance. Simulation debriefing allows for greater control and planning than are logistically feasible for on-the-job performance. It is also unique in that facilitators of simulation-based training are generally individuals external to the team, whereas debriefing on the job is commonly led by an internal team member or conducted without a specified facilitator. Consequently, there is greater opportunity for selecting and training facilitators for team simulation events. Thirteen Best Practices: The 13 best practices, extracted from existing training and debriefing research, are organized under three general categories: (1) preparing for debriefing, (2) facilitator responsibilities during debriefing, and (3) considerations for debriefing content. For each best practice, considerations and practical implications are provided to facilitate the implementation of the recommended practices., Conclusion: The 13 best practices presented in this article should help health care organizations by guiding team simulation administrators, self-directed medical teams, and debriefing facilitators in the optimization of debriefing to support learning for all team members.

Simulation-based training (SBT) affords practice opportunities for improving the quality of clinicians' technical and nontechnical skills. However, the development of practice scenarios is a process plagued by a set of challenges that must be addressed for the full learning potential of SBT to be realized. Scenario templates are useful tools for assisting with SBT and navigating its inherent challenges. This article describes existing SBT templates, explores considerations in choosing an appropriate template, and introduces the Template of Events for Applied and Critical Healthcare Simulation (TEACH Sim) as a tool for facilitating the formation of practice scenarios in accordance with an established evidence-based simulation design methodology. TEACH Sim's unique contributions are situated within the landscape of previously existing templates, and each of its component sections is explained in detail.

Background: TeamSTEPPS (Team Strategies and Tools to Enhance Performance and Patient Safety) is a team-training intervention which shows promise in aiding the mitigation of medical errors. This article examines the construct validity of the TeamSTEPPS Teamwork Perceptions Questionnaire (T-TPQ), a self-report survey that examines multiple dimensions of perceptions of teamwork within healthcare settings., Method: Using survey-based methods, 1700 multidisciplinary healthcare professionals and support staff were measured on their perceptions of teamwork. Confirmatory factor analysis was conducted to examine the relationship between the five TeamSTEPPS dimensions: Leadership, Mutual Support, Situation Monitoring, Communication, and Team Structure., Results: The analysis indicated that the T-TPQ measure is more reliable than previously thought (Cronbach's α=0.978). Further, our final tested model showed a good fit with the data (x(2) (df) 3601.27 (546), p<0.0001, Tucker-Lewis Index (TLI)=0.942, Comparative fit index (CFI)=0.947, root mean square error of approximation (RMSEA)=0.057), indicating that the measure appears to have construct validity. Further, all dimensions correlated with one another, but were shown to be independent constructs., Conclusions: The T-TPQ is a construct-valid instrument for measuring perceptions of teamwork. This has beneficial implications for patient safety and future research that studies medical teamwork., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Delays in care have been cited as one of the primary contributors of preventable mortality; thus, quality patient safety is often contingent upon the delivery of timely clinical care. Rapid response systems (RRSs) have been touted as one mechanism to improve the ability of suitable staff to respond to deteriorating patients quickly and appropriately. Rapid response systems are defined as highly skilled individual(s) who mobilize quickly to provide medical care in response to clinical deterioration. While there is mounting evidence that RRSs are a valid strategy for managing obstetric emergencies, reducing adverse events, and improving patient safety, there remains limited insight into the practices underlying the development and execution of these systems. Therefore, the purpose of this article was to synthesize the literature and answer the primary questions necessary for successfully developing, implementing, and evaluating RRSs within inpatient settings-the Who, What, When, Where, Why, and How of RRSs.

Background: Recognizing the need to minimize human error and adverse events, clinicians, researchers, administrators, and educators have strived to enhance clinicians' knowledge, skills, and attitudes through training. Given the risks inherent in learning new skills or advancing underdeveloped skills on actual patients, simulation-based training (SBT) has become an invaluable tool across the medical education spectrum. The large simulation, training, and learning literature was used to provide a synthesized yet innovative and "memorable" heuristic of the important facets of simulation program creation and implementation, as represented by eight critical "S" factors-science, staff, supplies, space, support, systems, success, and sustainability. These critical factors advance earlier work that primarily focused on the science of SBT success, to also include more practical, perhaps even seemingly obvious but significantly challenging components of SBT, such as resources, space, and supplies. SYSTEMS: One of the eight critical factors-systems-refers to the need to match fidelity requirements to training needs and ensure that technological infrastructure is in place. The type of learning objectives that the training is intended to address should determine these requirements. For example, some simulators emphasize physical fidelity to enable clinicians to practice technical and nontechnical skills in a safe environment that mirrors real-world conditions. Such simulators are most appropriate when trainees are learning how to use specific equipment or conduct specific procedures., Conclusion: The eight factors-science, staff, supplies, space, support, systems, success, and sustainability-represent a synthesis of the most critical elements necessary for successful simulation programs. The order of the factors does not represent a deliberate prioritization or sequence, and the factors' relative importance may change as the program evolves.